Urologic Oncology: Seminars and Original Investigations ] (]]]]) ]]]–]]]

Review article
A review of Agent Orange and its associated oncologic risk of
genitourinary cancers
Chrystal Chang, M.D.a,*, Michael Benson, M.D.a, Mina M. Fam, M.D.b
a
Department of Surgery, Division of Urology, Rutgers New Jersey Medical School, Newark, NJ
b
Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
Received 7 April 2017; received in revised form 20 August 2017; accepted 30 August 2017

Abstract
Agent Orange is an herbicide sprayed widely in Vietnam that is linked to a variety of malignancies in as early as 1991.Since then, there
has been concern for, and subsequent interest in studying, the potential connection between Agent Orange and other malignancies. In the
past 2 decades, there have been significant changes in the opinion of the National Academy of Science regarding Agent Orange and certain
genitourinary malignancies. Herein, we review the literature regarding the potential link between Agent Orange and various urological
cancers, including prostate, bladder, testicular, and renal cancers. r 2017 Elsevier Inc. All rights reserved.

Keywords: 2,3,7,8-tetrachlorodibenzo-p-dioxin; Agent Orange; Vietnam; Veteran; Cancer

1. Background increased association between Agent Orange and prostate

Agent Orange is an herbicide sprayed widely in Vietnam
from August 1965 to February 1971, and contains 2,3,7,8-
tetrachlorodibenzo-p-dioxin (TCDD). TCDD has been
shown to cause direct DNA damage and has been linked
to a variety of malignancies, especially non–Hodgkin’s
lymphomas, soft-tissue sarcomas, and cutaneous T-cell
lymphomas [1,2]. With these discoveries, there was sig-
nificant concern that Agent Orange could increase the risk
of other cancers as well. In recent years, there has been
interest in studying the potential connection between Agent
Orange and urologic malignancies. In 1991, Congress
enacted the Agent Orange Act, which mandated the
National Academy of Science to periodically review the
available literature regarding herbicidal exposure and var-
ious disease states. In the past 2 decades there have been
significant changes in the Academy’s expert opinions
regarding Agent Orange and certain genitourinary malig-
nancies. In 1998, the National Academy of Science stated
that there was “limited or suggestive evidence” of an
⁎
Corresponding author. Tel. (office): þ1-973-972-4465; fax: þ1-973-
972-3892.
E-mail address: chachang@njms.rutgers.edu (C. Chang).
cancer [3]. A recent update in March 2016 by the
Committee to Review the Health Effects in Vietnam
Veterans of Exposure to Herbicides has suggested that
there is “limited or suggestive evidence” of an increased
association between Agent Orange and bladder cancer [4].
Herein, we review the literature and case-control studies
regarding the potential link between Agent Orange and
various urological cancers, including prostate, bladder,
testicular, and renal cancers. Our paper serves to raise the
question that perhaps specific guidelines are needed to
address screening and possible changes in surveillance
protocols among patients who have had toxic chemical
exposures.
2. Biological plausibility of Agent Orange and
malignancy
Several studies have provided significant evidence cor-
roborating TCDDs association with malignancy. TCDD is
easily and rapidly absorbed via alimentary tract, yet
eliminated slowly. Oral administration can lead to 50% to
93% absorption of the administered dose [5]. The half-life
is exceedingly long, with some studies demonstrating a

http://dx.doi.org/10.1016/j.urolonc.2017.08.029
1078-1439/r 2017 Elsevier Inc. All rights reserved.
2 C. Chang et al. / Urologic Oncology: Seminars and Original Investigations ] (]]]]) ]]]–]]]
half-life of up to 7.2 years [6]. The mechanism by which
TCDD promotes carcinogenesis has not been completely
elucidated, but it is known that TCDD interacts intra-
cellularly with the ligand-activated aryl hydrocarbon recep-
tor (AHR) or the aryl hydrocarbon receptor nuclear
translocator (AHNR), or both [7]. This transcription factor
alters gene expression of factors such as platelet-derived
growth factor and vascular endothelial growth factor, which
are heavily implicated in carcinogenesis [7]. TCDD may
also indirectly promote aberrant cell growth by binding to a
portion of the AHR/AHNR complex, which would also
alter gene expression and cell function that potentially
promotes carcinogenesis [7]. These are mechanisms by
which chemical compounds such as TCDD provide intra-
cellular signals that can affect the nuclei of cells and lead to
increased risk of malignancy.
3. Prostate cancer
Prostate cancer has been the most common noncutaneous
malignancy in the United States since 1984, now account-
ing for 27% of all cancers and it is estimated that 1 in 7 men
alive today will be diagnosed with prostate cancer [8]. The
first study demonstrating an associated increased risk of
prostate cancer due to Agent Orange exposure was a case-
control study in 2004 at the Michigan Veterans Affairs
hospital, which showed that men with prostate cancer were
approximately 2 times more likely to report previous
exposure to Agent Orange (odds ratio ¼ 2.06, 95%
CI: 0.81–5.23) [9]. In 2013, the first statistically significant
study describing Agent Orange as a risk factor for high-
grade prostate cancer was completed at the Portland,
Oregon Veterans Affairs hospital. This study described
not only the positive association between herbicide expo-
sure and the overall risk of prostate cancer, but also a
twofold increased risk for high-grade (Gleason score: 8–10)
prostate cancer [10]. Additional studies concluded that
prostate cancer was diagnosed at a younger age and was
of a more aggressive variant in exposed veterans [11]. Other
international studies such as the Agent Orange Exposure
and Prevalence of Self-reported Diseases based out of
Korea further demonstrated the same relationship as was
seen in the US population studies [12]. Although based on
self-reported survey data, the Korean study with more than
100,000 respondents did demonstrate a greater than twofold
risk of prostate cancer in the high exposure group as
compared to the control group. Statistically significant and
associated studies describing incidence (Table 1) and
mortality (Table 2) are detailed later.
As seen in the aformentioned tables, several studies have
revealed a statistically significant increased incidence of
prostate cancer in veterans exposed to Agent Orange
[10,13–18]. The Akhtar et al. [15] study was first to
investigate cancer incidence among United States Vietnam
War veterans. Overall, there is an increased incidence of
prostate cancer in those who served longer in Vietnam and
had higher serum levels of TCDD [13,14]. However, no
study has been able to demonstrate increased risk of
mortality among those exposed to Agent Orange [19,20].
A review of the cited studies also reveals that although there
are many statistically significant studies, most studies utilize
small sample sizes with the exception of 2: The Northern
California self-reported survey-based study of 239 exposed
patients with prostate cancer, and the Australian-based
population study of 692 exposed patients with prostate
cancer [17,18]. In the former study, Chamie et al. [17]
provided one of the more comprehensive studies which
found that compared to unexposed men, Agent Orange-
exposed men were diagnosed with prostate cancer at a
younger age, had a twofold increase in the proportion of
Gleason scores 8 through 10 cancer, and were more likely
to have metastatic disease at presentation. The Australian
cohort study was a major contributor to the 2006 Agent
Orange update from the National Academy of Sciences,
where the stance was elevated to “limited or suggestive
evidence” of an increased association between Agent
Orange and prostate cancer, and that stance remains to this
day [4,18]. Veterans who served in Vietnam are around the
same age as the average age of diagnosis of prostate cancer,
age 67 [21], warranting increased need of prostate cancer
screening in veterans, specifically in those veterans who
were subject to environmental exposures.
4. Bladder cancer
Bladder cancer is a “cancer of the environment and age”
[22]. Links confirming genetic susceptibility to bladder
cancer have been made, such as NAT2 slow acetylator
and GSTM1-null genotypes [23]; however, external risk
factors appear to be of primary importance. The earliest
chemical agents associated with bladder cancer were
Benzidine and β-naphthylamine in dye and rubber workers
[24]. However, the most important known risk factor for
bladder cancer is tobacco smoke inhalation. Over the past
several decades, there has been considerable debate regard-
ing the carcinogenic effect of Agent Orange on the
urothelium, specifically in the bladder. The debate remains
contentious, as bladder cancer has not yet been considered a
service-connected disease process for Vietnam Veterans.
In their tenth biennial report, the Committee to Review
the Health Effects in Vietnam Veterans of Exposure to
Herbicides changed their previous stance on bladder cancer,
reporting that “epidemiologic results concerning an associ-
ation between exposure to the chemicals of interest (COIs)
and bladder cancer had accrued to now constitute limited or
suggestive evidence of an association” [4]. This change
provides a significant shift in previous reports which stated
that there was “inadequate or insufficient information to
determine whether there [was] an association” [22].
 C. Chang et al. / Urologic Oncology: Seminars and Original Investigations ] (]]]]) ]]]–]]] 3

Table 1
Incidence of prostate cancer in those exposed to Agent Orange [4]

Incidence

Population Exposed cases Agent Orange Relative risk Study

chemical of interest (95% CI)

US Air Force Ranch Hand Veterans—last tour in Southeast Asia before 9 All 1.0 (0.4–2.3) Pavuk et al. [13]
1969, heavy spraying with low recorded serum TCDD
US Air Force Ranch Hand Veterans—last tour in Southeast Asia before 15 All 2.3 (1.1–4.7) Pavuk et al. [13]
1969, heavy spraying with high recorded serum TCDD
US Air Force Ranch Hand Veterans—less than 2 years served in Southeast 20 All 1.9 (1.0–3.7) Pavuk et al. [13]
Asia, heavy spraying with high recorded serum TCDD
US Air Force Ranch Hand Veterans—less than 2 years served in Southeast 14 All 2.2 (1.0–4.5) Pavuk et al. [13]
Asia, heavy spraying with high recorded serum TCDD
1982–2003—White Southeast Asian (SEA) comparison veterans who 8 All 1.0 Pavuk et al. [14]
served 0.8–1.3 years in Southeast Asia
1982–2003—White SEA comparison veterans who served 1.3–2.1 11 All 1.3 (0.5–3.2) Pavuk et al. [14]
years in Southeast Asia
1982–2003—White SEA comparison veterans who served 2.1–3.7 26 All 2.2 (1.0–4.9) Pavuk et al. [14]
years in Southeast Asia
1982–2003—White SEA comparison veterans who served 3.7–16.4 36 All 2.4 (1.1–5.2) Pavuk et al. [14]
years in Southeast Asia
Ranch Hand Veterans vs. National Rates, through 1999 36 All 1.5 (1.0–2.0) Akhtar et al. [15]
SEA veterans with tours between 1966–1970 vs. National Rates, 42 All 1.6 (1.2–2.2) Akhtar et al. [15]
through 1999
SEA veterans vs National Rates, through 1999 54 All 1.6 (1.2–2.1) Akhtar et al. [15]
Exposed veterans with radical prostatectomies examined in VA Not reported All 1.5 (1.1–2.0) Shah et al. [16]
Healthcare facilities (California, Georgia, North Carolina)
Northern Californiaprostate cancer (self-reported [before diagnosis] 239 All 2.9 (2.3–3.6) Chamie et al. [17]
of AO exposed vs. not)
Oregon veterans who underwent prostate biopsy at Portland VA 74 All 1.5 (1.1–2.1) Ansbaugh et al. [10]
Medical Center diagnosed with prostate cancer
Oregon veterans who underwent prostate biopsy at Portland VA 40 All 1.8 (1.1–2.7) Ansbaugh et al. [10]
Medical Center diagnosed with Gleason Score 47 prostate cancer
Oregon veterans who underwent prostate biopsy at Portland VA Not reported All 2.1 (1.2–3.6) Ansbaugh et al. [10]
Medical Center diagnosed with Gleason Score 48 prostate cancer
Australian Vietnam Veterans who served on land or in Vietnamese 692 All 1.3 (1.2–1.3) ADVA [18]
waters 5/23/1962–7/1/1973 vs. Australian population

Previously most of the evidence among military service
members was gathered from 6 studies (Tables 3 and 4).
None of these studies provided any evidence for
increased incidence of bladder cancer or mortality due to
bladder cancer in those Veterans exposed to TCDD.
However, most recently a large population-based study
was released from South Korea. 177,899 Korean Vietnam
veterans were analyzed for exposure to TCDD and risk of
death using the Korean National Health Insurance claims
data from January 1992 to December 2005. First, exposure
to TCDD was quantified in a logarithmic fashion based on
the Veteran’s military unit. A high exposure group and low
exposure group were then compiled based on logarithmic
exposure index scores (Table 5).
In this study, there was a statistically significant twofold
increase in disease-specific mortality in the high exposure
group. It is possible that this increased mortality was not
seen earlier as bladder cancer typically has a latency period
between exposure and detection that may take many
decades. However, given the above data and previous
information from occupational studies, the Veterans com-
mittee on Agent Orange has changed its position and stated

Table 2
Mortality of prostate cancer in those exposed to Agent Orange [4]

Mortality

Population Exposed cases Agent Orange chemical of interest Relative risk (95% CI) Study

Australian Vietnam Veterans, all Branches, return—2001 107 All 1.2 (1.0–1.5) ADVA [19]
Australian Conscripted Army National Service, 1982–1994 36 All 1.5 (1.0–2.0) CDVA [20]
4 C. Chang et al. / Urologic Oncology: Seminars and Original Investigations ] (]]]]) ]]]–]]]

Table 3
Incidence of bladder cancer in those exposed to Agent Orange [4]

Incidence

Population Exposed cases Agent Orange chemical of interest Relative risk (95% CI) Study

US Vietnam Veterans, Air Force 14 All 1.1 (0.6–1.7) Akhtar et al. [15]
Massachusetts Vietnam-era veterans 80 All 0.6 (0.2–1.3) Clapp [25]
Australian Vietnam Veterans 164 All 1.0 (0.9–1.2) ADVA [18]
Australian Conscripted Army National Service 19 All 0.7 (0.4–1.1) ADVA [26]

that there is “limited or suggestive evidence of an associ-
ation” between Agent Orange exposure and bladder cancer:
a significant change from their previously held expert
opinion. This change may clinically change screening and
surveillance patterns among clinicians who care for patients
with known Agent Orange exposure. Also, the above
evidence may have serious financial implications for those
veterans whose care and compensation are affected by a
service-connected disease process related to an occupational
exposure.
5. Testicular cancer
Testicular cancer occurs most often in men between the
ages of 20 and 34 [31]. Known risk factors for testicular
cancer include white race [31], cryptorchidism [32], family
history [33,34], and infertility [35]. Agent Orange as a risk
factor for the development of testicular cancer has not been
thoroughly explored, likely due to the early presentation
and rarity of the disease.
The most recent study, conducted by Yi and Ohrr,
examined Korean Vietnam Veterans (high exposure
n ¼ 85,809 vs. low exposure n ¼ 94,442) and identified
5 cases of incident testicular cancer: 2 with high exposure
and 3 with low exposure. Overall, there was no difference
in the incidence of testicular cancer in this cohort compared
to the general Korean population (standardized incidence
ratio ¼ 1.03, CI: 0.42–2.63) [36]. Additionally, there was
no association for testicular cancer when comparing
individuals with high exposure to individuals with
low exposure [30]. Multiple other studies describing
incidence and mortality were reviewed and are outlined in
Tables 6 and 7 later.
Although multiple studies attempted to ascribe a poten-
tial link between Agent Orange exposure and an increased
risk of testicular cancer, the data simply are not powered
well enough to support this connection. This may be due to
the fact that testicular cancer occurs most often in men
between the ages of 25 and 29, and today’s Vietnam
veterans are well outside that age range. Moreover, men
who have received a diagnosis of testicular mass, absence
of one testicle, undescended testicle, or testicular cancer
would have been medically disqualified from service [42],
which could also help explain a seemingly slight reduction
in risk observed in some of the studies outlined earlier.
6. Renal cancer
Renal cancer occurs predominantly in the sixth to eighth
decades of life, is uncommon in patients younger than 40
years, and is rare in children [43]. It is estimated that in the
United States, 39,650 men and 23,050 women will be
diagnosed with renal cancer in 2016, and that 9,240 men
and 5,000 women will die from it [44]. Numerous risk
factors have been implicated in renal cancer including
tobacco use, occupational exposure to toxic compounds
such as cadmium, asbestos, and petroleum by-products,
obesity, acquired cystic kidney disease, and analgesic abuse
nephropathy [45,46]. Few studies exist exploring Agent
Orange as a risk factor for developing renal cancer. Table 8
describes 8 studies among the Vietnam veteran population
that have been inconclusive in attributing an association

Table 4
Mortality of bladder cancer in those exposed to Agent Orange [4]

Mortality

Population Exposed Agent Orange Relative risk Study

cases chemical of interest (95% CI)

US CDC Vietnam experience study 1 All 1.0 (0.4–2.6) Boehmer et al. [27]
US Vietnam-era Army veterans who served 7/4/1965–3/1/1973 9 All 0.6 (0.3–1.2) Breslin et al. [28]
US Vietnam-era Army Marine veterans who served 4 All 2.4 (0.1–66.4) Breslin et al. [28]
7/4/1965–3/1/1973
Australian Vietnam Veterans 22 All 0.7 (0.4–1.0) ADVA [19]
Australian Conscripted Army National Service 1 All 0.3 (0.0–1.7) CDVA [20]
 C. Chang et al. / Urologic Oncology: Seminars and Original Investigations ] (]]]]) ]]]–]]]
Table 5
Agent Orange exposure and risk of death [29]
Population Exposure Exposed cases Agent Orange chemical of interest
Korean Veteran Health Study Low exposure 19 All
High Exposure 42 All
between increased incidence of, or mortality from, RCC due
to Agent Orange exposure.
The Committee to Review the Health Effects in Vietnam
Veterans of Exposure to Herbicides has therefore taken the
stance that “there is inadequate or insufficient evidence to
determine whether there is an association between exposure
to Agent Orange and renal cancers” [4]. There are few
studies exploring a potential association between Agent
Orange and renal cancer, as well as a low number of
exposed cases in these studies with only 3 of 8 studies
having more than 30 exposures. Not studies were able to
reach statistical significance in determining a relationship
between Agent Orange exposure and renal cancers.
7. Discussion
Agent Orange, an herbicide used during the Vietnam
War, contains compounds such as TCDD that have been
linked to an increased incidence of malignancies. Although
TCDDs association with urological malignancies has only
recently been explored, there is “limited or suggestive
evidence” of an increased association between Agent
Orange and prostate and bladder cancer [4]. Agent Orange
is linked not only to an increased incidence in prostate
cancer, but also to a higher grade cancer in exposed cohorts.
In regards to bladder cancer, in 2016 the Committee to
Review the Health Effects in Vietnam Veterans of Exposure
to Herbicides altered its stance on the relationship between
Agent Orange and bladder cancer from “inadequate or
insufficient evidence,” to “limited or suggestive evidence”
[4]. Considering these findings, it is increasingly important
to screen today’s Vietnam veterans for potential exposure to
Agent Orange, as well as assess their risk of both prostate
and bladder cancers. Patients who have risk factors for
Table 6
Incidence of testicular cancer in those exposed to Agent Orange [4]
Incidence
Population
District of Columbia Vietnam Veterans diagnosed in 1976–June 30, 1981
Massachusetts Vietnam-era veterans aged 35–65 years in 1993 diagnosed
in 1988–1993 vs. gastrointestinal cancers
Australian Vietnam Veterans, all branches, 1982–2000
Australian Conscripted Army National Service, 1982–2000
Korean Vietnam Veterans, high exposure (n ¼ 2) and low exposure (n ¼ 3)
5
Relative risk (95% CI) Study
1.13 (0.98–1.29) Yi and Ohrr [30]
2.04 (1.17–3.55)
developing these cancers, such as significant smoking
history, are at an even higher risk. It is important to
clinically monitor Vietnam veterans for developing prostate
cancer, and earlier intervention may be warranted. The
studies reviewed should help raise awareness among
Vietnam veterans and clinicians to discuss potential Agent
Orange exposure as an important part of a comprehensive
medical history. It may also be prudent to consider the
Vietnam Veterans who were exposed to Agent Orange as a
more “high risk” patient demographic for prostate cancer,
similar to men of African-American heritage or men with
family history of prostate cancer.
As of now, there are a limited number of studies
assessing Agent Orange’s relationship with testicular and
renal cancer. A potential increased incidence of testicular
cancer in Vietnam veterans secondary to Agent Orange
exposure is unlikely to be adequately studied given
significant constraints: the population of Vietnam Veterans
today is outside the age range of those who typically
develop testicular cancer (at ages 25–29), and the rates of
the disease process are extremely low, making it difficult to
demonstrate statistical significance. In regards to renal
cancer, no studies were able to determine a positive
correlation between Agent Orange and renal cancer.
A potential issue in many of the reported studies include
recall bias of Vietnam veterans regarding their exposure
status. Objective data to quantify TCDD exposure, such as
serum measurements of TCDD, does not exist. Instead,
several studies relied on geographic models to extrapolate
exposure. Furthermore, there exists a potential bias for
patients to admit to Agent Orange exposure, as there is
financial compensation for those who have been exposed
and subsequently developed malignancy. Finally, the over-
all small sample sizes in most of the initial studies make
results at times difficult to interpret with confidence.
Exposed Agent Orange chemical Relative risk Study
cases of interest (95% CI)
31 All 2.3 (1.0–5.5) Tarone et al. [37]
30 All 1.2 (0.4–3.3) Clapp [25]
54 All 0.9 (0.6–1.1) ADVA [18]
17 All 0.7 (0.4–1.2) ADVA [26]
5 All 1.05 (0.42–2.63) Yi and Ohrr [30]
6 C. Chang et al. / Urologic Oncology: Seminars and Original Investigations ] (]]]]) ]]]–]]]

Table 7
Mortality of testicular cancer in those exposed to Agent Orange [4]

Mortality

Population Exposed Agent Orange Relative risk Study

cases chemical of interest (95% CI)

US Vietnam Veterans: VA Cohort of Army Chemical Corps 2 All 4.0 (0.5–14.5) Dalager and Kang [38]
US Vietnam Veterans: Army, deployed 109 All 1.2 (not significant) Watanabe et al. [39]
US Vietnam Veterans: Marine Corps, deployed 28 All 0.8 (not significant) Watanabe et al. [39]
US Vietnam Veterans: Army, deployed 90 All 1.1 (0.8–1.5) Breslin et al. [28]
US Vietnam Veterans: Marine Corps, deployed 26 All 1.3 (0.5–3.6) Breslin et al. [28]
923 White male Vietnam veterans with Wisconsin death certificate 9 All 1.0 (0.5–1.9) Anderson et al. [40,41]
(1968–1978) vs proportions for Vietnam-era veterans
Australian Vietnam Veterans, All branches, return–2001 14 All 0.9 (0.4–1.4) ADVA [19]
Australian Conscripted Army National Service, 1966–2001 4 All 0.8 (0.2–2.0) ADVA [26]

Table 8
Incidence of renal cancer in those exposed to Agent Orange [4]

Incidence

Population Malignancy Exposed Agent Orange chemical Relative risk Study

cases of interest (95% CI)

Korean Vietnam Veterans Renal cell carcinoma 181 All 0.7 (0.6–1.0) Yi and Ohrr [30]
Korean Vietnam Veterans Renal pelvis cancer 23 All 1.1 (0.4–2.5) Yi and Ohrr [30]
Australian Vietnam Veterans Renal cancers 125 All 1.0 (0.8–1.2) ADVA [18]
Australian Conscripted Army National Service Renal cancers 19 All 0.7 (0.4–1.0) ADVA [36]
US Army Vietnam veterans, deployed Renal cancers 55 All 0.9 (0.5–1.5) Breslin et al. [28]
US Marines Vietnam veterans, deployed Renal cancers 13 All 0.9 (0.5–1.5) Breslin et al. [28]
Massachusetts Vietnam veterans diagnosed 1972–1983 Renal cancers 9 All 1.8 (1.0–3.5) Kogan and Clapp [47]
Michigan Vietnam-era veterans Renal cancers 21 All 1.4 (0.9–2.2) Visintainer et al. [48]

In addition, some studies in which Vietnam veterans
were compared with the general population may have
demonstrated the “healthy-soldier effect,” where Vietnam
veterans had a lower all-cause mortality than general
population [49]. Owing to initial physical screens where
potential military personnel are required to be in optimal
physical condition compared to the general population,
there could be underestimation of the effect of Agent
Orange, or any toxic exposure in Vietnam veterans com-
pared to the general population.
There are not many high quality studies investigating an
association between Agent Orange exposure and urologic
malignancies. Moreover, further extensive evaluation is not
likely to occur, as the population of Vietnam Veterans
exposed to Agent Orange is undergoing decline. Though
there is a link to prostate cancer and potentially bladder
cancer, the magnitude of the clinical implications and the
patient recommendations that should be made in response to
these increased risks are not well described. Additional
research needs to be undertaken to further elucidate the
relationship between Agent Orange and testicular and renal
cancers as well. As we are learning ever more about how
Agent Orange and its role in genetic mutations affect one’s
risk of future malignancy, we feel that previous exposure to
its carcinogenic chemicals should be approached with
enhanced suspicion. It may be pertinent to address possible
changes in screening and surveillance protocols among
patients who have been exposed to Agent Orange.
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